Clinical Edits

The Texas Managed Medicaid STAR/CHIP formulary, including the Preferred Drug List and any clinical edits, is defined by the Texas Vendor Drug Program.

Texas Vendor Drug Program Clinical Edit Website: https://www.txvendordrug.com/formulary/prior-authorization/care-clinical-prior-authorization

Please click on the link(s) below to view the Texas Medicaid STAR and CHIP implemented clinical edits.

Click here for Prior Authorization information.

Type	Name		File Size
PDF File	Accolate Eff. Date: 02/07/2023	ACCOLATE, ZAFIRLUKAST	469 KB
PDF File	ADD_ADHD Eff. Date: 09/12/2022	ADDERALL, AMPHETAMINE, AMPHETAMINE ER, AMPHETAMINE/DEXTROAMPHET SALTS, AZSTARYS, ADZENYS, ADZENYS-ODT, AMPHETAMINE/DEXTROAMPHET SALTS ER, ADHASIA XR, APTENSIO XR, CLONIDINE, CONCERTA ER, COTEMPLA, DAYTRANA, DESOXYN, DEXMETHYLPHENIDATE, DEXEDRINE, DEXMETHYLPHENIDATE, DYANAVEL, EVEKEO, FOCALIN XR, FOCALIN, GUANFACINE, INTUNIV, JORNAY, METHAMPHETAMINE, METHYLIN, METHYLPHENIDATE, METHYLPHENIDATE ER, METHYLPHENIDATE CD, MYDAYIS, PROCENTRA, QELBREE, QUILLICHEW, QUILLIVANT, RITALIN, STRATTERA, VYVANSE, ZENZEDI	741 KB
PDF File	Agents for Gaucher’s Disease - HHSC Eff. Date: 12/01/2022	CERDELGA, CEREZYME, ELELYSO, MIGLUSTAT, VPRIV, ZAVESCA	410 KB
PDF File	Aliskiren - HHSC Eff. Date: 07/05/2022	ALISKIREN, TEKTURNA	2 MB
PDF File	Allergen Extracts - HHSC Eff. Date: 12/01/2022	ORALAIR	792 KB
PDF File	Amantadine Extended-Release Agents - HHSC Eff. Date: 10/18/2022	GOCOVRI ER, OSMOLEX ER	610 KB
PDF File	Antiemetics - HHSC Eff. Date: 07/05/2022	AKYNZEO, APREPITANT, EMEND, GRANISETRON HCL, SANCUSO	717 KB
PDF File	Antipsychotics Eff. Date: 08/01/2022	ABILIFY, ABILIFY DISCMELT, ABILIFY MAINTENA, ABILIFY MYCITE, AMITRIPTYLINE/PERPHENAZINE, ASENAPINE, ARIPIPRAZOLE, ARISTADA ER, CAPLYTA, CHLORPROMAZINE, CLOZAPINE, CLOZAPINE ODT, CLOZARIL, FANAPT, FAZACLO, FLUPHENAZINE, GEODON, HALOPERIDOL, INVEGA ER, INVEGA HAFYERA, INVEGA SUSTENNA, INVEGA TRINZA, LATUDA, LOXAPINE, LYBALVI, MOLINDONE HCL, OLANZAPINE, OLANZAPINE ODT, OLANZAPINE/FLUOXETINE, ORAP, PALIPERIDONE ER, PERPHENAZINE, PERSERIS ER, PIMOZIDE, QUETIAPINE , REXULTI, RISPERDAL , RISPERDAL CONSTA, RISPERDAL M-TAB, RISPERIDONE, SAPHRIS, SECUADO, SEROQUEL, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS	346 KB
PDF File	Antiseizure Agents (Epidiolex and Fintepla) - HHSC Eff. Date: 10/22/2022	EPIDIOLEX, FINTEPLA	813 KB
PDF File	Anxiolytics and Sedatives Hypnotics (ASHs) - HHSC Eff. Date: 11/29/2022	ALPRAZOLAM, XANAX, CHLORDIAZEPOXIDE, MEPROBAMATE, OXAZEPAM, DIAZEPAM, CLONAZEPAM, KLONOPIN, CLORAZEPATE, TRANXENE T, LORAZEPAM, TEMAZEPAM, TRIAZOLAM, ZOLPIDEM, ESTAZOLAM, RESTORIL, TEMAZEPAM, ESZOPICLONE, LUNESTA, SONATA, ZALEPLON, INTERMEZZO, ZOLPIDEM, AMBIEN, EDLUAR, BELSOMRA, BUTISOL SODIUM, FLURAZEPAM, HETLIOZ, ROZEREM, DAYVIGO	3 MB
PDF File	Arikayce HHSC Eff. Date: 07/05/2022	ARIKAYCE	628 KB
PDF File	Buprenorphine Agents – HHSC Eff. Date: 07/19/2021	BUNAVAIL, BUPRENORPHINE, BUPRENORPHINE-NALOXON, SUBOXONE, ZUBSOLV	1 MB
PDF File	Carisoprodol - HHSC Eff. Date: 10/20/2022	CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND, CARISOPRODOL CPD-CODEINE, CARISOPRODOL, SOMA	260 KB
PDF File	CGRP Antagonists Acute Eff. Date 04/01/2022	NURTEC, UBRELVY	674 KB
PDF File	CGRP Antagonists, Prophylaxis HHSC Eff. Date 11/08/2022	AIMOVIG, AJOVY, EMGALITY, NURTEC, QULIPTA	782 KB
PDF File	Cholestatic Pruritis Agents HHSC Eff. Date: 10/20/2022	BYLVAY, LIVMARLI	743 KB
PDF File	CNS Stimulants - HHSC Eff. Date: 10/20/2022	ARMODAFINIL, MODAFINIL, NUVIGIL, PROVIGIL, SUNOSI, WAKIX	406 KB
PDF File	Contraceptives - CHIP ONLY Eff. Date: 10/22/2012		22 KB
PDF File	Contraceptives - Dell Children’s Health Plan Only Eff. Date: 12/09/2016		18 KB
PDF File	Cough/Cold Medications - HHSC Eff. Date: 11/18/2022	ALA-HIST, ALLFEN DM TAB, AP-HIST DM LIQ, APRODINE TAB, BENZONATATE, BROMFED DM CGH SYR, BROMPHENIR-PSEUDO-DM SYR, BROTAPP, CHEST CONG RELIEF, CHLD DELSYM, CHLD COLD & CGH DM ELIXI, CHLD MUCINEX, CHLD DAYCLEAR ALL CGH, CHLO TUSS LIQ, CGH DM, CGH SYR, DALLERGY, DECONEX DMX TAB, DECONEX IR TAB, DELSYM, DEXTROMETHORPHAN ER, DIMAPHEN, ED A-HIST, ED BRON GP LIQ, ED CHLORPED D PEDIATRIC DROPS, ENDACOF-DM LIQ, EX ACTION CGH SYR, GUAIFEN, GUAIFEN ER, GUAIFEN/PSE, HISTEX, IOPHEN, KIDKARE CGH & COLD LIQ, KID'S MUCINEX MINI-MELTS PACK, LODRANE D CAPSULE, LOHIST, LORTUSS, MAXIPHEN, M-END DMX LIQ, M-HIST DM LIQ, MUCINEX, MUCUS RELIEF, NASAL DECON SPRAY, NASOPEN PE LIQ, NIGHT CGH LIQ, NINJACOF LIQ, NOHIST, NOSE DROPS, ORGAN-I, PED CGH-COLD LIQ, PHENYLEPHRINE-PYRILAMINE, POLY HIST, POLY-VENT, POLYTUSSIN, PROMETHAZINE, Q-TUSS, RESCON, RESPAIRE-30, ROBAFEN, RU-HIST D, RYMED, SILTUSS, SINUS RELIEF 1% NASAL SPRAY, SM NASAL SPRAY, SM TUSS DM, STAHIST AD, SUDOGEST SINUS & ALLERGY, TUSS, VANACOF, VANATAB	1 MB
PDF File	Cystic Fibrosis Agents - HHSC Eff. Date: 09/21/2022	KALYDECO, ORKAMBI, SYMDEKO, TRIKAFTA	2 MB
PDF File	Cytokine and CAM Antagonists Eff. Date: 02/07/2023	ACTEMRA, ARCALYST, CIBINQO, CIMZIA, COSENTYX, ENBREL, ENSPRYNG, HUMIRA, ILARIS, ILUMYA, KEVZARA, KINERET, OLUMIANT, ORENCIA, OTEZLA, RINVOQ, SILIQ, SIMPONI, SKYRIZI, STELARA, TALTZ, TREMFYA, XELJANZ	2 MB
PDF File	Desmopressin Eff. Date: 02/07/2023	DDAVP, DESMOPRESSIN ACETATE	1014 KB
PDF File	Dextromethorphan Overutilization - HHSC Eff. Date: 03/12/2020	ALA-HIST DM LIQ, AP-HIST DM LIQ, ALLFEN DM TAB, BROMFED DM CGH, BROMPHENIR-PSEUDO-DM SYR, BROTAPP DM LIQ, CHILD DELSYM, CHILD C&C DM ELIX, CHILD MUCINEX, DECONEX DMX TAB, DELSYM 30MG/5ML SUSP, DELSYM CGH+CHEST CNGST DM LQ, DEXTROMETHORPHAN ER 30MG/5ML, DIMAPHEN DM ELIX, ED-A-HIST DM LIQ, ED-A-HIST DM TAB, ENDACOF-DM LIQ, EXT ACTION CGH SYR, GUIAFEN-DM ER 1,200-60MG TAB, HISTEX-DM SYR, IOPHEN DM-NR LIQ, KIDKARE C&C LIQ, LOHIST-DM SYR, LORTUSS DM LIQ, M-END DMX LIQ, M-HIST DM, MAXIPHEN DM TAB, MUCINEX CGH MINI-MELT PACK, MUCINEX DM ER 600-30MG TAB, MUCINEX DM ER 1,200-60MG TAB, MUCINEX FAST-MAX CONG-CGH, MUCINEX FAST-MAX DM MAX LIQ, NOHIST-DM LIQ, PED C&C LIQ, POLY-HIST DM LIQ, POLY-VENT DM TAB, POLYTUSSUN DM, PROMETH-DM SYR, Q-TUSS DM SYR, RESCON-DM LIQ, ROBAFEN CF LIQ, ROBAFEN-DM, ROBAFEN CGH 15MG LIQGEL, ROBAFEN DM CGH-CHEST CONG SYR, RYNEX DM LIQ, SILTUSS DM CGH SYR, SILTUSS DM DAS LIQ, SM TUSS DM, TUSS DM, VANACOF DM LIQ, VANACOF DMX, VANATAB DM CAP, VIRDEC DM DRP	220 KB
PDF File	Diacomit - HHSC Eff. Date: 10/22/2022	DIACOMIT	628 KB
PDF File	Diclofenac - HHSC Eff. Date: 10/20/2022	DICLOFENAC GEL 3%, DICLOFENAC SOL 1.5%, PENNSAID SOL 2%	300 KB
PDF File	Dopamine Agonists - HHSC Eff. Date: 02/22/2021	APOKYN, KYNMOBI	606 KB
PDF File	Doxylamine/Pyridoxine - HHSC Eff. Date: 10/29/2019	BONJESTA ER, DICLEGIS DR	254 KB
PDF File	DPP4 Inhibitors - HHSC Eff. Date: 3/27/2019	ALOGLIPTIN, ALOGLIPTIN-METFORMIN, ALOGLIPTIN-PIOGLIT, GLYXAMBI, JANUMET, JANUMET XR, JANUVIA , JENTADUETO, JENTADUETO XR , KAZANO, KOMBIGLYZE XR , NESINA, ONGLYZA , OSENI , QTERN , STEGLUJAN, TRADJENTA	314 KB
PDF File	Emflaza - HHSC Eff. Date: 10/07/2021	EMFLAZA	753 KB
PDF File	Enzymes - HHSC Eff. Date: 8/23/2022	ALDURAZYME, CEPROTIN, ELAPRASE, FABRAZYME, GALAFOLD, NAGLAZYME, NITYR, ORFADIN, REVCOVI, STRENSIQ, VIMIZIM	1 MB
PDF File	Erythropoiesis-Stimulating Agents - HHSC Eff. Date: 10/28/2022	ARANESP, EPOGEN, PROCRIT, RETACRIT	1 MB
PDF File	Evrysdi - HHSC Eff. DAte: 06/09/2022	EVRYSDI	793 KB
PDF File	Fentanyl Agents - HHSC Eff. Date: 07/18/2022	ACTIQ, FENTANYL, FENTORA	3 MB
PDF File	GI Motility Agents - HHSC Eff. Date: 10/18/2022	AMITIZA, IBSRELA, LINZESS, ALOSETRON HCL, LOTRONEX, MOVANTIK, MOTEGRITY, RELISTOR, SYMPROIC, TRULANCE, VIBERZI	2 MB
PDF File	GLP1 Receptor Agonist HHSC Eff. Date: 06/02/2022	ADLYXIN, BYDUREON, BYETTA, MOUNJARO, OZEMPIC, RYBELSUS, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY	787 KB
PDF File	Growth Hormone - HHSC Eff. Date: 06/08/2022	GENOTROPIN, HUMATROPE, NORDITROPIN NORDIFLEX, NORDITROPIN FLEXPRO, NUTROPIN AQ, OMNITROPE, SAIZEN, SEROSTIM, SKYTROFA, ZORBTIVE	2 MB
PDF File	Hereditary Angioedema (HAE) - HHSC Eff. Date: 11/16/2022	BERINERT, CINRYZE, FIRAZYR, HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO	683 KB
PDF File	HP Acthar - HHSC Eff. Date: 12/02/2022	HP ACTHAR GEL	405 KB
PDF File	Hyperlipidemia Agents (PCSK9 Inhibitors) - HHSC Eff. Date: 10/07/2021	JUXTAPID, PRALUENT, REPATHA	1 MB
PDF File	Imiquimod - HHSC Eff. Date: 10/19/2022	ALDARA, IMIQUIMOD, ZYCLARA	736 KB
PDF File	Increlex - HHSC Eff. Date: 10/19/2022	INCRELEX	969 KB
PDF File	Inhaled Antibiotics HHSC Eff. Date: 10/28/2022	BETHKIS, CAYSTON, KITABIS PAK , TOBI, TOBRAMYCIN	260 KB
PDF File	Ketorolac (Toradol) - HHSC Eff. Date: 10/28/2022	KETOROLAC	382 KB
PDF File	Keveyis - HHSC Eff. Date: 10/28/2022	KEVEYIS	275 KB
PDF File	Lidocaine Patch - HHSC Eff. Date: 11/07/2019	LIDOCAINE, LIDODERM, LIDOPURE PATCH, ZILACAINE PATCH, ZTLIDO	306 KB
PDF File	Lovaza - Vascepa - HHSC Eff. Date: 07/05/2022	LOVAZA, VASCEPA	824 KB
PDF File	Lupus Agents - HHSC Eff. Date: 10/22/2021	BENLYSTA, LUPKYNIS	993 KB
PDF File	Makena Eff. Date: 05/01/2022	MAKENA	254 KB
PDF File	Monoclonal Antibody Agents - HHSC Eff. Date: 10/28/2022	ADBRY, DUPIXENT, FASENRA, NUCALA, XOLAIR	2 MB
PDF File	MS Agents - HHSC Eff. 05/24/2022	AMPYRA, AUBAGIO, DALFAMPRIDINE, MAVENCLAD, MAYZENT, PONVORY, ZEPOSIA	1 MB
PDF File	Neurontin (Gabapentin) HHSC Eff. Date: 10/28/2022	GABAPENTIN, GRALISE, HORIZANT, NEURONTIN	673 KB
PDF File	Nitazoxanide (Alinia) - HHSC Eff. Date: 05/24/2022	NITAZOXANIDE	678 KB
PDF File	Nuplazid - HHSC Eff. Date: 3/29/2019	NUPLAZID	419 KB
PDF File	Ophthalmic Immunomodulators - HHSC Eff. Date: 04/28/2022	EYSUVIS, RESTASIS MULTIDOSE, RESTASIS EYE EMULSION, TYRVAYA, XIIDRA	601 KB
PDF File	Opioid Policy Criteria - HHSC Eff. Date: 12/15/2022	APAP-CAFF-DIHYDROCOD, APAP-COD, ACTIQ, APADAZ, ASCOMP/COD, BELBUCA, BELLADONNA-OPIUM, BUPRENORPHINE, BUTALB-APAP-CAFF-COD, BUTALB-CAFF-APAP-COD, BUTALBITAL COMP-COD, BUTORPHANOL, BUTRANS, CARISOPRODOL CPD-COD, COD-GUAIFEN, COD SULFATE, DEMEROL, DILAUDID, DOLOPHINE HCL, DSUVIA, DURAGESIC, DVORAH, EMBEDA ER, ENDOCET, FENTANYL, FENTORA, FIORINAL-COD, GUAIFEN-COD , GUAIATUSSIN AC, HYDROCODON-APAP, HYDROCODONE BT-IBU, HYDROCODONE-CHLORPHEN ER, HYDROCOD-HOMATROPINE, HYDROCODONE BT-IBU, HYDROCODONE-IBU , HYDROMET, HYDROMORPHONE, HYDROMORPHONE ER, HYSINGLA ER, KADIAN ER, LAZANDA NASAL SPRAY, LEVORPHANOL, LORCET, MEPERIDINE, METHADONE, METHADOSE, MORPHABOND ER, MORPHINE, MS CONTIN, NALBUPHINE, NALOCET, NINJACOF-XG, NORCO, NUCYNTA, NUCYNTA ER, OPIUM, OXYCODONE, OXYCODONE-APAP, OXYCODONE-ASA , OXYCODONE-IBU, OXYCONTIN, OXYMORPHONE HCL, OXYMORPHONE HCL ER, PENTAZOCINE-NALOXONE, PERCOCET, PROMET-COD, ROXICODONE, SUBSYS SPRAY, TRAMADO, TYLENOL COD, ULTRACET, ULTRAM, VICODIN, VIRTUSSIN, XTAMPZA ER	1 MB
PDF File	Oriahnn - HHSC Eff. Date: 10/28/2020	ORIAHNN	884 KB
PDF File	Orilissa - HHSC Eff. Date: 3/29/2019	ORILISSA	403 KB
PDF File	Oxervate - HHSC Eff. Date: 12/02/2022	OXERVATE	270 KB
PDF File	Oxycodone Extended Release - HHSC Eff. Date: 10/31/2022	OXYCONTIN, OXYCODONE HCL ER, XTAMPZA ER	2 MB
PDF File	Palforzia - HHSC Eff Date: 10/19/2022	PALFORZIA	606 KB
PDF File	PDE5 - Inhibitors - HHSC Eff. Date: 10/31/2022	ADCIRCA, REVATIO, SILDENAFIL, TADALAFIL	685 KB
PDF File	Phosphate Binders - HHSC Eff. Date:02/02/2022	AURYXIA, CALCIUM ACETATE, CALPHRON, FOSRENOL, LANTHANUM CARB, PHOSLYRA SOL, RENAGEL, RENVELA, SEVELAMAR, VELPHORO	818 KB
PDF File	Promethazine Agents - HHSC Eff. Date: 10/19/2022	PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHEGAN	551 KB
PDF File	Propylthiouracil - HHSC Eff. Date: 10/31/2022	PROPYLTHIOURACIL	399 KB
PDF File	Pulmonary Arterial Hypertension Oral/Inhaled Eff. Date: 02/07/2023	ADEMPAS, LETAIRIS, OPSUMIT, ORENITRAM ER, TRACLEER, TYVASO, UPTRAVI, VENTAVIS	220 KB
PDF File	Pulmozyme HHSC 01/24/2022	PULMOZYME	590 KB
PDF File	Qelbree- HHSC 07/28/2021	QELBREE	753 KB
PDF File	Ranexa - HHSC Eff. Date: 10/31/2022	RANEXA	374 KB
PDF File	Recorlev HHSC Eff. Date: 04/22/2022	RECORLEV	849 KB
PDF File	Savella - HHSC Eff. Date: 3/29/2019	SAVELLA	669 KB
PDF File	SGLT2 Inhibitor Agents HHSC Eff. Date: 08.01.2022	FARXIGA, INVOKANA, JARDIANCE, STEGLATRO	800 KB
PDF File	Sickle Cell Agents - HHSC Eff. Date: 10/19/2022	OXBRYTA	741 KB
PDF File	Symlin - HHSC Eff. Date: 3/29/2019	SYMLIN, SYMLINPEN	250 KB
PDF File	Synagis - HHSC Eff. 09/15/2022	SYNAGIS 50 MG/0.5 ML VIAL, SYNAGIS 100 MG/1 ML VIAL	842 KB
PDF File	Thiazolidinediones - HHSC Eff. Date: 11/11/2020	ACTOPLUS MET, ACTOPLUS MET XR, PIOGLITAZONE-METFORMIN, ACTOS, DUETACT, PIOGLITAZONE HCL, PIOGLITAZONE-GLIMEPIRIDE, AVANDIA	977 KB
PDF File	Topical Acne Agents Eff. Date: 4/01/2022	AMZEEQ FOAM, BENSAL HP OINTMENT, BENZACLIN GEL, BENZEFOAM, CLINDAMYCIN FOAM, CLINDAMY/BEN GEL, ERY/BENZOYL GEL, FINACEA FOAM, FINACEA GEL, METRONIDAZOLE LOTION	655 KB
PDF File	Topical Antifungals for Onychomycosis - HHSC Eff. Date: 10.22.2021	CICLOPIROX SOL, JUBLIA SOL, KERYDIN SOL, TAVABOROLE SOL	930 KB
PDF File	Topical Immunomodulators Eff. Date: 02/07/2023	ELIDEL, EUCRISA, OPZELURA, PROTOPIC, TACROLIMUS	756 KB
PDF File	Topical Retinoids Eff. Date: 04/01/2022	ADAPALENE, ADAPALENE-BENZYL PEROX, AKIEF, ALTRENO LOTION, ARAZLO, ATRALIN, AVITA, CLINDA-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, TRETINOIN GEL MICRO, ZIANA GEL	414 KB
PDF File	Transthyretin Agents - HHSC Eff. Date: 10/08/2021	TEGSEDI, VYNDAMAX, VYNDAQEL	738 KB
PDF File	Urea Cycle Disorder HHSC Eff. Date: 4/26/2019	BUPHENYL, CARBAGLU, RAVICTI, SODIUM PHENYLBUTYRATE	169 KB
PDF File	VMAT2 - HHSC Eff. Date: 10/15/2021	AUSTEDO, INGREZZA, XENAZINE	1 MB
PDF File	Voxzogo HHSC Eff. Date: 04/22/2022	VOXZOGO	625 KB
PDF File	Wakix - HHSC Eff. Date: 10/08/2021	WAKIX	675 KB
PDF File	Xifaxan (Rifaximin) - HHSC Eff. Date: 3/29/2019	XIFAXAN	288 KB
PDF File	Xyrem - HHSC Eff. Date: 10/08/2021	XYREM, XYWAV	670 KB
PDF File	Zelboraf - HHSC Eff. Date: 10/08/2021	ZELBORAF	682 KB
PDF File	Zyflo Eff. Date: 02/07/2023	ZYFLO	483 KB

Type

Date

Name

File Size

.txt

2/1/2023

Texas-STAR-Kids-Dual-Formulary-2-1-2023

859 kB

.txt

2/1/2023

Texas-STAR-Formulary-2-1-2023

3.2 MB

.txt

2/1/2023

Texas-CHIP-Formulary-2-1-2023

2.4 MB